ECMO Learning Package

2016
EXTRA CORPOREAL OXYGENATION (ECMO)

LEARNING PACKAGE
Paula Nekic, CNE Liverpool ICU SWSLHD

SSWAHS
February 2016
Liverpool Hospital Intensive Care: Learning Packages Intensive Care Unit
ECMO Learning Package
CONTENTS
Anatomy 3
ECMO Definition 5
Indications / Contraindications 6
ECMO Equipment 7
Cannulation 12
Types of ECMO 14
CVVHDF with ECMO 18
Management 19
Nursing management 22
Complications / Troubleshooting 26
Weaning from ECMO 33
Learning Activities 34
Reference List 35
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ANATOMY5,8
 Superior vena cava
 Carries deoxygenated blood from the veins from the upper body then into
right atrium
 Inferior vena cava
 Carries deoxygenated blood from the lower body to right atrium
 Aorta
 Carries oxygenated blood from the Left ventricle to the organs
 Pulmonary artery
 Carries deoxygenated blood from the Right ventricle to the lungs
Principle veins and arteries
 Veins carry blood to heart
 Arteries carry blood away from heart to lungs to be oxygenated
EXTRA CORPOREAL MEMBRANE OXYGENATION (ECMO)

Definition:1,7
ECMO is a form of extracorpeal life support where an external artificial circulator carries
venous blood from the patient to a gas exchange device (oxygenator) where blood becomes
enriched with oxygen and has carbon dioxide removed. This blood then re-enters the
patient’s circulation.
Circuit flow is achieved using a pump either centrifugal or a roller pump.
ECMO evolved from cardiopulmonary by-pass.
Patients who are hypoxaemic despite maximal conventional ventilatory support, who have
significant ventilator-induced lung injury or who are in cardiogenic shock may be considered
for ECMO support. For respiratory failure, the basic premise is that ECMO will allow the level
of ventilatory support to be reduced, which may allow time for recovery from the underlying
pathology and recovery from ventilator-induced lung injury to occur.
There are two types of ECMO, veno-venous and veno- arterial.
Figure 1: ECMO Circuit
INDICATIONS1,2,7
ECMO is indicated for potentially reversible, life-threatening forms of respiratory and / or
cardiac failure, which are unresponsive to conventional therapy and it, is always applied at
the discretion of the managing intensivist or cardiac surgeon.
 Respiratory failure
 ALI/ARDS
 Aspiration
 Pneumonia
 Asthma
 Post lung transplant
 Lung contusion
 Cardiac Failure
 Post cardiac arrest
 Pulmonary embolus
 Drug overdose
 Post cardiac surgery
 Bridge to transplant
 Post heart transplant
 Cardiogenic shock
CONTRAINDICATIONS
1,2,7
Absolute Contraindications
 Severe irreversible neurological condition
 Encephalopathy
 Cirrhosis with ascites
 History of variceal bleeding
 Moderate-severe chronic lung disease
 Terminal malignancy
 HIV
Absolute Contraindications to Veno-Venous ECMO

 Severe left ventricular failure EF <25%
 Cardiac arrest
Absolute Contraindications to Veno-Arterial ECMO

 Aortic dissection
 Severe aortic regurgitation
Relative Contraindications1,2,7
 Age >65
 Multiple trauma with uncontrolled haemorrhage
 Multi-organ failure
Relative Contraindication to Veno-Venous ECMO

 High pressure / high FiO2 IPPV for >1 week
Relative Contraindication to Veno-Arterial ECMO

 Severe peripheral vascular disease
ECMO EQUIPMENT1,2
Perfusion Services are responsible for providing an ECMO pump and a primed circuit when
ECMO is initiated in the ICU. They should be contacted as early as possible after the
decision to commence ECMO is made. In and out of hours, the cardiothoracic team on call is
brought in to establish ECMO (including the medical perfusionist), details of the on-call staff
are kept in ICU, and with the hospital switchboard. A spare ECMO circuit for exchange in the
event of pump failure is available in the theatre pump room.
 Circuit priming and preparation are performed exclusively by Perfusion Services and
equipment for this function is stored in Theatre. Perfusion staff provides 24 hours
emergency cover for this role.
ECMO Cannulae (stored in Theatre)

 Arterial Kits 50cm Medtronic Biomedicus cannulae: sizes: 19 and 21F
 Venous Kits 150 cm Medtronic Biomedicus cannulae: sizes: 19, 23 and 27
ECMO: initial set-up items:

 Centrifugal pump module
 Hand crank
 Brackets for Rotaflow oxygenator / pump
ECMO pack
 1x 1L crystalloid
 2x tubing clamps
Further items that should remain with the patient:
 Spare ECMO circuit

 2x single transducer kits (Rotaflow)
 ECMO operating notes, trouble-shooting guide and observation chart
 Rota-flow / Cardiohelp manual
 4 sterile tubing clamps
 Sterile heavy scissors
 Heparin-bonded 3/8 –3/8 connectors
 Silicon paste (for Rotaflow flow probe)
 ACT machine and tubes
 Heater-cooler
 Cable ties and gun
 30cm monitoring extension lines for use with CVVHD
SWEEP GAS & OXYGENATOR CENTIFUGAL PUMP & SENSOR
OXYGENATOR &
HAND CRANK
HEATER / COOLER
Figure 2: ECMO Equipment
Oxygenator
 The oxygenator has a semi permeable membrane
 Blood flows across one side while a “sweep” gas 100% O2 moves in opposite
direction
 The higher the gas flow rate the more CO2 is removed
Sensor
 Measures the flow
 Needs cream applied to function. Wrap in cling –wrap
Centrifugal Pump
 The circuit flow is achieved using a pump: either centrifugal or a roller
 Centrifugal is used for ECMO at Liverpool
 The centrifugal pump has a priming volume of 32mls which reduces haemodilution
Figure 3: Centrifugal pump
Rotaflow drive
 The drive is what the pump sits in and the blood flow is measured in the pump outlet by
ultrasonic sensor
 The sensor requires regular placement of cream to maintain function
Cream applied here
Figure 4: Rotaflow drive Rotaflow emergency hand crank
Rotaflow emergency hand crank

 This is utilised when there is a pump failure
 There is an LED display of the pump speed on the side of the drive
Pump Console
 Provides the controls for pump blood flow rate and speed
 Battery backup of 90 minutes
 It can be incorporated into the bypass machine or stand alone mode
Blood flow rate: LPM
Pump speed: RPM
Dial for controlling pump speed
Modes
Alarm Silence
Power
Figure 5: Pump console
Heater / Cooler Machine

 A heater cooler machine is attached to oxygenator to regulate patient temperature
 Aim to maintain normothermia
Figure 6: Heater/cooler
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Pressure Monitoring1,2
Inflow and outflow pressures from the oxygenator reflect the performance of the oxygenator
The pre-membrane pressure is at a connector near the venous inlet of the oxygenator
The post membrane pressure is measured at the connector on the oxygenator’s arterial
outlet
These pressures are displayed on a separate monitor with the ECMO circuit
Pre and post

membrane
pressures
Figure 7: Pressure Monitoring
The difference between the pre and post membrane pressure gives you the trans-
membrane pressure gradient.
The trans-membrane pressure gradient should be less than 50mmHg
An increase in the trans-membrane pressure gradient may indicate clot formation within the
oxygenator
A steadily increasing trans-membrane pressure without a concomitant increase in the circuit

flows may indicate that the oxygenator needs to be replaced
Pre membrane
pressure outlet
Post membrane
pressure outlet
Figure 8: Pressure monitoring points post oxygenator
CANNULATION4,6,7
There are three ways of accessing the major vessels for ECMO:
 Surgical central cannulation
 Surgical peripheral cannulation
 Percutaneous cannulation
Sites
 Venous cannulation sites include the internal jugular veins, femoral veins and the right
atrium.
 Arterial cannulation sites are the carotid arteries, femoral arteries and the aorta.
Sizes
Range in size from 16F -23F
Anti-coagulate patient prior to insertion
Percutaneous preferable to cut down to minimise bleeding
TOE utilised to confirm correct placement in IVC
Figure 9: ECMO Cannulae
Positioning of Cannulae
V-V ECMO
Access cannula:
 For femoral insertion, use TOE (Trans Oesophageal ECHO) to confirm that the wire is in
the IVC, position the cannula tip in the IVC below the level of the diaphragm; (~35-40 cm
in an adult);
 Use the Avalon introducer kit to dilate the vessel to about 1 size below the cannula
gauge; the tips of the femoral return and access lines should be separated by about 10cm
to avoid recirculation
 If high flow rates are required, a second access line is inserted in the SVC, via the right
internal jugular vein; use ultrasound to assess the diameter of the IJV and to confirm that
the wire is in the IJV and SVC; insert the cannula ~15 cm
Return cannula:
 Use TOE to confirm that the wire is in the IVC and to position the cannula tip at the
IVC/RA junction
Avalon cannula:
 Maximum flow from the largest (31F) catheter is 5 Lpm
 Consider for any patient up to 90 kg
 Ensure that the right IJV is patent
 Use the Avalon introducer kit, during serial dilation of the vein and during
 final cannula placement
 With TOE or TTE (Trans Thoracic ECHO), ensure that the guidewire remains well inside
the IVC at all times, to minimise the risk of cardiac perforation
 The final position of the cannula should be at least 3cm into the IVC
 ensure that the return jet is directed towards the tricuspid valve before
 securing the cannula to the patient’s neck
Figure 10: The Avalon Elite Multi-Port Venous Femoral Catheter
V-A ECMO
Access cannula:
 Femoral insertion, use TOE to confirm that the wire is in the IVC and to position the
cannula tip in the RA
Return cannula:
 The arterial (short) cannula should be fully inserted to the length of the cannula
Backflow cannula:
 Used to prevent ischemia occurring distally to the arterial cannulation site in peripheral V-
A ECMO
 Inserted in the artery distal to the ECMO cannulation site
 Connected to the luer connector on the arterial cannula by a piece of extension tubing
 Should be inserted and connected at the time of cannulation, or as soon as practical later
 After arrival in ICU, the ultrasonic flow probe should be used to confirm that there is flow
in the extension tubing
Access Cannula
(Venous)
Return Cannula
(Arterial)
Tubing to backflow
cannula
Doppler examination of the blood flow in the back-flow cannula is indicated if deteriorating
leg perfusion is observed in the cannulated leg.
TYPES OF ECMO4,6,7
There are two basic types which are described by the site of drainage & where the blood
returns
Veno-venous
 Deoxygenated blood is drained from venous circulation into the ECMO circuit
 Blood is oxygenated via the oxygenator and is returned to the right atrium
 Drains from major vein & returns to a major vein
 Supports only the lungs
 Adequate circulation is provided by the native cardiac output
Veno-arterial
 Deoxygenated blood is drained from venous circulation into the ECMO circuit
 Passes through the oxygenator and is returned directly to the arterial
circulation
 Drains from major vein & returns to major artery
 Supports heart & lungs
Figure 11: ECMO Circuit
VENO VENOUS ECMO

Involves venous blood from the patient being accessed from the large central veins (via the
“access line”) and returned to the venous system near the right atrium (via the “return line”)
after it has passed through an oxygenator.
It provides support for severe respiratory failure when no major cardiac dysfunction exists.
When flow through a single access cannula is insufficient to support the high ECMO flow
rate that may be required in severe respiratory failure, a second venous access cannula may
be required.
V–V ECMO improves the patient’s oxygenation by reducing the amount of blood that passes
through the lung without being oxygenated and in addition removes CO2 from the patient’s
blood.
This allows the level of ventilatory support to be reduced, which reduces ventilator-induced
lung injury.
The efficiency of oxygenation by the ECMO circuit depends on the pump flow relative to the
patient’s cardiac output.
The patient’s oxygenation should increase with increasing ECMO flow rate, if this does not
occur, recirculation of blood between the inflow and outflow cannulae should be suspected
Second access cannula :using SVC
Access cannula: using IVC
Return cannula
Figure 12: An example of Veno-venous ECMO
V-V ECMO and CO2:
V-V ECMO is more efficient at removing CO2 from the blood than delivering oxygen.
The amount of CO2 removal depends on the ECMO flow rate relative to the patient’s cardiac
output and also depends on the oxygen flow rate (sweep gas) to the oxygenator.
Increasing oxygen flow rate decreases the CO2 in the blood leaving the oxygenator
(analogous to the effect that increasing minute ventilation has on arterial PCO2)
The oxygen flow rate (the sweep flow) to the oxygenator should be roughly twice the ECMO
flow rate. Eg: if the ECMO Flow rate is 3L, the oxygen flow rate shoud be 6L. With an ECMO
flow rate of approximately 2/3 the patient’s cardiac output, and an oxygen flow rate of twice
the pump flow, nearly all of the patient’s CO2 production can be removed by the oxygenator.
V-V ECMO and O2:

Arterial O2 is determined by the relationship between the ECMO pump flow and the patients
cardiac output
If the ECMO pump flow is low compared to patients cardiac output the arterial O2 will also be
low
Increasing the ECMO pump flow will increase the O2 in the mixed venous circulation &
therefore increase the arterial O2
Providing ECMO pump flows equal to 66% of the patients cardiac output will achieve a
saturation of > 90% (Locker et al., 2003)
Common for patients on V-V ECMO to have PO2 in range of 55-90mmHg
In Summary
 To remove CO2 increase the O2 sweep gas
 To increase the p02 you increase the pump flow
VENO-ARTERIAL ECMO
Involves venous blood from the patient being accessed from the large central veins and
returned to a major artery after it has passed through the oxygenator.
It provides support for severe cardiac failure, (usually with associated respiratory failure),
most commonly after cardiac surgery
Access cannula
Return cannula
Figure 13: An example of Veno – Arterial ECMO
May be used at low rates (2-3L/min) to provide partial assistance or at high rate of 4-6L/min
to totally replace the patients cardiac output
All gas exchange is delivered directly to arterial circulation so PO2 levels 400-500mmHg can
be achieved
Changing flow rates will not affect arterial PO2 but will determine the patients cardiac output
ECMO circuit malfunctions will result in cardiac arrest as the ECMO flow rate is the patients
cardiac output
V-A ECMO may be applied via central or peripheral cannulation
If peripheral cannulation is applied any residual native cardiac output passes through the
lungs. If the lungs are affected by disease or mechanical ventilation is insufficient the blood
of the residual cardiac output will remain hypoxic as it enters the systemic circulation
Anatomically there is potential for this hypoxic blood will be delivered to the head, neck and
right arm.
Therefore any patient on peripheral V-A ECMO should have O2 saturations measured on the
forehead or right hand
Patients on V-A ECMO require adequate ventilation with FiO2 of at least 50%to reduce the
risk of coronary and cerebral hypoxia
Carbon dioxide removal is controlled by the sweep gas flow rates as in V-V ECMO, but if
there is some native cardiac output and the lungs are ventilated normally some CO2 will be
removed by the lungs
V-V AND V-A ECMO
V-V V-A
 Provides respiratory support  Provides complete respiratory

& hemodynamic support
 Blood from and returned to
venous circulation  Blood from venous circulation
then returned to arterial
 Less arterial injury circulation
 Decreased likelihood air or  Bridge to recovery or for heart
clot emboli from the circuit
transplant
 Low pressure circuit therefore  Pump flow is the pt CO, any
improving longevity of circuit disruption to flow = cardiac
 Decreased hemodynamic arrest
instability as blood is returned  All gas exchange in
and withdrawn from same oxygenator is delivered to
side arterial circulation = arterial
 Achieves arterial p02 55- p02 400-500mmHg
90mmHg
 Changing flow rates affects
 Changing flow rates affects cardiac output
p02
 Increasing O2 sweep gas

removes more CO2
CONNECTING CVVHDF TO ECMO

The Prismaflex machine can be connected to the ECMO circuit. This should be done by the
perfusionist. Once the ICU nurse has been trained in this procedure it may be done by the
nurse. If the ICU nurse is unsure on how to make the connections the perfusionist must be
called. The ECMO circuit is a high pressure circuit and opening taps and connections will
result in air entering system or blood spills.
The access and return lines of the dialysis machine are attached to the ECMO circuit to the
two three-way taps between the outlet of the pump head and the oxygenator.
ACCESS:
 Access line goes to the three way tap closet to the centrifugal pump
 If pressure within ECMO circuit causes high pressure alarm in Prismaflex change access
pressure alarm in set up to positive. Always should select positive ACCESS Pressure for
ECMO and CRRT.

Centrifugal pump
CRRT
Access line
Figure 14: Access Line for CRRT connection to ECMO Circuit
RETURN:
 Return line is connected to three way tap closest to the oxygenator
 3 way taps not to be flushed with any solution including sodium chloride
 Betadine to wipe connections when disconnecting from ECMO
Oxygenator
Return line
Figure 15: Return Line for CRRT connection to ECMO Circuit
MANAGEMENT1,4,6,7
Commencement of ECMO:
 Check ACT and ensure >200 seconds
 Ensure oxygen line is connected to oxygenator. Gas flow should be commenced at a rate
equal to or greater than the anticipated circuit blood flow (usually 5-6L/min)
 Clean loop is opened and handed to the cannulating physician
 The circuit is cut between two clamps allowing sufficient length on the access line and
return line to prevent any tension on the circuit. Note the pump trolley is best kept at the
“feet” end of the patient’s bed (picture)
 Circuit is connected to cannulae ensuring no air is introduced
 Clamps removed as circuit flows are gradually increased
 Target flow rates are determined by the cannulating Physician
 For V-V ECMO target flows must provide adequate arterial oxygenation
 For V-A ECMO target flows must provide adequate oxygen delivery
 Check patient and circuit arterial blood gases
 Reduce ventilator settings as indicated
 Establish baseline anticoagulation sampling times.
Securing Access and Return Lines

 Once the cannulae position has been confirmed femoral lines should be secured by
suturing to patients leg and then using large opsite over the top of the cannulas. The
internal jugular line is best stabilised by directing the tubing around the head before
passage down the body to the oxygenator. The loop around the head is immobilised by
strapping around the patient’s forehead
Figure 16: Securing ECMO Lines
Care of Equipment:
 Ensure AC power alarm is turned on when using wall power

 Keep pump head in a position to minimise risk of accidental contact with other equipment
e.g. X-ray machine
 Ensure heater cooler hoses & O2 flow tubing is not obstructed by feet, bed etc
 Don’t allow any part of the circuit to come in contact with alcohol or organic solvents
Medical Staffing:
There is a medical perfusionist (a cardiac anaesthetist) and a pump technician available 24
hours for:
 Initiation of ECMO
 Priming of circuits
 ECMO circuit maintenance and nursing support
Out of hours (1800 to 0800 weekdays and weekends), the medical perfusionist may be
contacted directly or via switchboard.
Their contact details should be left at the patient’s bedside.

They should be contacted about all circuit and patient issues related to ECMO.
The ICU consultant is responsible for all medical decisions involving ECMO while the patient
is in ICU and must also be notified of any changes. They can be contacted 24 hours.
Respiratory Management
Once adequate ECMO flows have been established and the patient’s oxygenation has
improved, the level of ventilatory support is reduced.
Typical ventilatory goals would be:

 FiO2 <0.7,
 PIP < 35cmH2O,
 PEEP < 15cmH2O
 respiratory rate < 10bpm (V-A)
Pump Flow rates:

 Flow rates: V-V
 2/3 of pts cardiac output, minimum 50% of patient’s cardiac output
 O2 flow rate twice ECMO flow rate
 Avoid increasing fluids to maintain pump flow as this may decrease
respiratory function
 Lowest SaO2 85-90% or PaO2 of 55-60
 Flow rates V-A
 Flow rate 2.1- 2.4l/min/m2
 ECMO flows less than 2litres for long periods should be avoided to prevent clots in circuit
Figure 17: Pump flow rates
Line pressures:
 Pre-membrane pressure <300mmHg
 Trans membrane gradient normal <50mmHg if > 150mmhg consider circuit change
Temperature:
 Normothermia, set heater cooler at 37degrees
 The heater-cooler settings should only be altered by the perfusion staff unless the nurse
has been trained to do this. Should the patient become unexpectedly hypo- or
hyperthermic while on ECMO, the medical perfusionist on call must be contacted
immediately.
Anticoagulation:
Although the ECMO circuit has an anticoagulant lining, low-dose heparin is usually
administered to prevent clot formation
 The ACT is usually used to titrate heparin infusion rate in the first 24 hours and is
measured 6 hourly over the first day. It is performed by the attending nurse, using 2 mls
of arterial or venous blood.
 A usual target for ACT in the non-bleeding patient with platelet count > 80,000 is 140–
160.
 Beyond 24 hours, the APTT performed in the Haematology lab is primarily used to guide
heparin therapy. It is performed 4 times per day and is routinely labelled as urgent to
ensure safe response times.
 A usual target for APTT in the non -bleeding patient with platelet count > 80,000 is 45-
55sec.
Investigations required for patients on ECMO include:

 Daily CXR
 Daily bloods: FBE; Urea, Creatinine, Electrolytes; Mg; PO4; LFT
 Clotting: APTT, INR, Fibrinogen are performed daily (morning bloods)
 APTT is performed 6 hourly as determined by the ICU consultant while the patient is on
ECMO.
 Plasma free Hb is performed when clinically indicated. The safe range for this is < 0.1g/L.
Levels above this MUST be discussed with ICU Consultant and medical perfusionist.
 Daily d-Dimers should be preformed
 Blood cultures 3 times per week or as indicated. Unlike other patients, these samples
should be taken from the circuit or through existing lines. Do NOT perform venipuncture
for the collection of blood cultures. (Samples from circuit are obtained by a perfusionist)
 Other cultures as indicated
Figure 18: ECMO Cannula on X-ray
General management
 Doppler examination of the blood flow in the back-flow cannula is indicated if deteriorating
leg perfusion is observed in the cannulated leg.
 Antibiotics (IV vancomycin) to prevent line sepsis are commenced at the start of ECMO.
Other antibiotics are prescribed as indicated.
 Stress ulcer prophylaxis is standard.
 No procedure can be performed on a patient on ECMO without the consent of the ICU
consultant.
 Protamine is contraindicated for patients on ECMO as it can cause serious circuit related
thrombosis
 All changes to circuit flows, gas and blood, should be relayed to the medical perfusionist
via ICU Senior Registrar
 All changes to circuit anticoagulation should be relayed to the medical perfusionist via
ICU Senior Registrar
Nursing Management1,4,6,7
Nursing responsibilities are to patient care. Responsibility for technical maintenance of the
ECMO circuit lies with the medical and technical perfusionists Liverpool Hospital.
Patient positioning and the safe performance of pressure area care are affected by
ECMO support.
 Patients with ECMO support with an “open sternum” may not be rolled and require
alternate means of preventing pressure area care eg: KCI mattress. Daily chest x-rays
and other patient moves require a Jordan Frame and the presence of medical staff and/or
perfusionist to ensure no change in circuit flow result as a consequence of movement.
 Other patients on ECMO support can be log-rolled and moved for chest x-rays. These
moves can be safely performed but require a designated staff member to ensure no
tension is transmitted to the cannulae and the circuit tubing is not kinked. This includes
patients with surgical grafts for femoral artery access but extra care is required to prevent
obstruction to ECMO flow at this site. Moves are scheduled between the hours of 0800
and 2000 and not during the night (unless there is an urgent patient need).
 All moves are to be performed with medical staff knowledgeable in ECMO, immediately
available to assess any circuit changes that may occur.
 Patients nursed at 2:1 nursing ratio
The ECMO patient must NOT be left unattended at any time

 Relief for breaks should be arranged so that a suitably experienced member of staff is
monitoring the patient and ECMO circuit at all times
 The ECMO patient is dependent on the circuit for maintenance of oxygenation +/- cardiac
output
 Any disruption to ECMO flow will result in rapid deterioration, which if not rapidly rectified
will result in death
Safety checks
 ECMO plugged into blue power point
 Hand crank near by
 Secure oxygen flow to oxygenator
 Check flow settings
 Check Pump access line for chattering

 Patient must not be left unattended at any time
Hourly observations
 Pump flow rate
 ECMO observation chart Nursing ECMO observation chart must be maintained and
reviewed by the rostered medical perfusionist. Nursing staff can communicate any
difficulties with observations with the rostered perfusionist. This data will form part of the
medical record.
 Haemodynamic observations
 Continuously monitor patient and ECMO set for drop in BP/ CVP
 Evidence of hypovolaemia in the form of fluctuating flow rates and ‘shaking’ of ECMO
tubes
 Hypovolaemia (relative or absolute) may result in disrupted blood flow through the
circuit
 Sucking down of the access cannula against the vessel wall may occur in
hypovolaemia potentially causing trauma to vessel endothelium and haemolysis
 Blood flow through the ECMO circuit is essential for maintenance of gaseous
exchange, and also to maintaining haemodynamic stability
 Pre & post membrane pressure
 Oxygen flow to oxygenator

 Ensure oxygen tubing is secured to floor
 Check flow on oxygen outlet
 Patient temperature
 Temperature measurement should be initiated and continuously monitored throughout
ECMO therapy via either blood thermister in the presence of a PiCCO/ PA catheter
 To promote homeostasis, normal body temperature must be maintained, unless mild
hyperthermia is clinically desired
 Continuous monitoring allows for early detection and therefore management of
temperature changes
 Access & return cannula for bleeding

 Observe for oozing of blood, and maintain secure dressings
 Secure dressings are required to maintain cleanliness of cannulae sites, and also to
help stabilise the cannulae
 Circulation observations lower limbs

 Limb temperature
 Limb colour
 Pedal pulses
 Capillary refill
 Due to the large bore cannulae distal arterial perfusion may be compromised in A-V
ECMO, while the venous cannulae may lead to DVT formation
 Input & output, haematuria

 Haematuria is often present when there is haemolysis, and therefore should be
reported and investigated appropriately
 Ventilation observations should be attended: mode, Fi02, Tidal volume, respiratory rate,
PEEP, pressure support, inspiratory time, plateau pressure.
 Patient should be nursed in the supine position

 Head of bed should be elevated 30 degrees
 Pressure relieving mattress should be insitu (because of decreased mobility and
perfusion sate these patient often high risk for pressure areas).
 Heel pressure should be offloaded.
 If patient needs to be moved a designated person must watch cannulae, tubing & flow
rates
 Patient need to be Jordan framed. They can be log rolled if not contraindicated.
 Neurological and pupillary assessment must be attended hourly (they are at increased
risk of intracranial bleed).
 Pain scores with CPOT (Critical Pain Observation Tool) and sedation scores with RASS
(Richmond Agitation Sedation Score) should be attended 2nd hourly. Daily sedation
vacations are attended to assess underlying neurological assessment.
ECMO OBSERVATION CHART (example)

DATE:- ________________ ( Record observations hourly)
TYPE:- ____________ COMMENCED:- _____________ FILTER CHANGED:-____________
TIME PUMP FLOW PUMP RPM INFLOW LINE OUTFLOW LINE PO2 IN
RATE PRESSURE PRESSURE OUTFLOW
(PRE) (POST) LINE
0100
0200
0300
0400
0500
0600
0700
0800
0900
1000
1100
1200
1300
1400
Circuit Management:1,2,4
The Jostra Quadrox D oxygenator is remarkably robust and is capable of several weeks of
continuous function.
Figure 18: Membrane Oxygenator
The oxygenator should be positioned in the oxygenator arm

The oxygenator’s performance must be monitored by:
 Recording the trans-membrane pressure gradient (the difference in pressure between the
inflow and outflow side of the oxygenator)
 Blood gas analysis of the oxygenator outflow
 Trans-membrane pressure should be recorded hourly
 Blood gases from the oxygenator outflow (“post- membrane”) should be performed every
12 hours (Rotaflow only).
Circuit change is indicated if :

 There is a trend towards increasing transmembrane pressures and / or worsening
oxygenator function (oxygenator outflow PaO2 < 150mmHg).
 A normal transmembrane pressure gradient is <50mmHg.
 The decision to change the oxygenator will be based on the trend of transmembrane
pressures and oxygenator performance and should also be considered if the ECMO
circuit is thought to be a source of sepsis.
The Jostra Rotaflow pump is capable of several weeks of continuous operation.
The pump head is kept with the outlet at 6 o clock
Figure 19: Oxygenator and Pump
It is important to ensure that the pump RPM rate is not too high for the maximum flow that
can be delivered (“over-spinning” the pump).
When the maximum pump flow rate has been attained (which is determined by the rate of
venous drainage in the access line), increasing the RPM further will increase the negative
pressure in the access line, producing ‘line-shake’ and increasing the risk of haemolysis.
“Over-spinning” of the pump is corrected by dropping the pump RPM until the flow rate
starts to drop.
Because the rate of venous drainage in the access line is variable, if the pump RPM is
constant and the venous drainage falls (eg. due to decreased preload), the pump will over-
spin and access flow limitation will start to occur.
Increased noise from the pump head may indicate that it is starting to fail. The other
indications for changing the pump head are the development of haemolysis (producing
haematuria and an increased plasma free haemoglobin) and large thrombus formation within
the pump head.
COMPLICATIONS / TROUBLESHOOTING1,2,4,7
VENO- VENOUS ECMO
 Hypoxia
Check
 Pump flow is > 2/3 pt cardiac output (e.g. CO 6l = 4l pump flow)
 100% 02 to oxygenator
 Check Oxygenator :outflow pO2>150mmHg
Management
 Increase pump flow
 Increase ventilation
 Cool pt to 35deg
 Muscle relaxants
 Correct anaemia
 Second access line to reduce shunt
 Hypercarbia
Check
 Pump flow is > 2/3 cardiac output

 Oxygen flow to oxygenator twice pump flow rate( e.g. if pump flow 4l, O2 flow 8l)
Management
 Increase pump flow rate otherwise consider that recirculation may be occurring
 Cool patient to 35°C
 Administer muscle relaxants
 Shunting/ Recirculation
Access & return cannulae too close may cause recirculation of blood, so Pump flow may not
improve oxygenation
Check
 Pre membrane (venous) pO2 < 50mmHg
Management
 Reposition access line
VENO- ARTERIAL ECMO

 Differential hypoxaemia
 Lower p02 in upper body compared to lower body
 Can occur when there is severe respiratory failure with a high cardiac output
 Heart supplies upper body with de-oxygenated blood & ECMO supplies lower body
with oxygenated blood
Check
 Patient ABG sample from right radial arterial line (close to heart)
 O2 saturation measured on right hand or forehead
Management
 Ensure proper functioning of oxygenator return line p02 >150mmhg
 Pump flow as high as possible
 Increase ventilation/ PEEP / Fi02
 Resite return line from femoral to right subclavian artery
 Hypercarbia
Check
 Adequate pump flow > 2/3 CO
 O2 to oxygenator is twice pump flow rate
Management
 Increase pump flow rate
 Cool pt
 Paralysis pt
BLEEDING
 Prevention is primary objective
 ACT’s day 0; APTT 6hrly
 Daily FBC, d-Dimer, fibrinogen
 Anticoagulation management with heparin APTT 50-75 sec
 If patient bleeding
 Cease heparin. Heparin coated circuits can run for couple days without heparin
 Investigate cause
 Platelets, Cryoprecipitate, FFP, packed cells
HAEMOLYSIS
 Breakdown of RBC
Causes
 Clot in the circuit or near cannulae orifice
 Access & return insufficiency or obstruction
 “over spinning” of pump speed
Signs
 Red or dark brown urine
 High K+
 Renal failure
 Jaundice (late sign)
 Access line shaking due to changes in pressure
Management
 Plasma free haemoglobin measured
 Increase volume
 Review pump flow settings
 TOE to ensure cannulae not obstructed
 Consider changing circuit
ECMO FLOW DECREASED RPM UNCHANGED
Ecmo policy and guideline: RPAH. P.Forrest. 2007
 Management
 Optimise fluid status
 Optimise preload afterload & contractility
 Sedation & analgesia before pressure care etc
 If complete “suck down” occurs decrease pump speed to reduce suction on catheter &
then turn up as to normal as smoothly & quickly as possible
 Consider extra venous drainage cannulae
“SIG” ALARM ON PUMP CONSOLE

 Flow rate indicator on pump says “SIG” while the pump is still functioning normally. RPM
is unchanged
 Occurs as cream under the flow sensor has dried out
 Management
 Contact perfusionist
 Re- establish full ventilation
 Stop pump slowly & clamp inflow & outflow lines to pump head
 Unclip black clip & remove pump head
 Apply silicone cream
 Reinsert head & close clip
 Unclamp lines & slowly restart flow
 Wrap sensor in cling wrap to prevent drying out
Sensor
EMERGENCY COMPLICATIONS1,2,4,7
 Dramatic and life threatening that require immediate action
 General rules
 Call for help, Intensivist, CT surgeon, Perfusionist
 Clamp
 Ventilate, haemodynamic support
PUMP FAILURE
 No flow due to electrical failure or pump head disengagement
 If circuit stopped for any period clotting is possible
 Prevention:
 Always maintain the pump head in a position to minimise the risk of contact especially
with devices such as portable x-ray, haemofilter and TOE
 Minimise time on battery
 Ensure AC “Power Off” alarm is turned on when using wall power
 Console not in use, needs to be plugged into AC power and “on Switch” turned on in
order to recharge battery
V-V V-A
 Hypoxaemia / hypercarbia  Cardiac arrest if circuit providing

which may lead to cardiac full C.O
arrest
 If some native C.O extent of
hypotension & hypoxia depends
on cardiac function
 Management
 Call for help
 Ventilate & haemodynamic support
 Electrical motor failure
▪ Clamp line & turn off pump
▪ If the cause is not immediately rectified, commence hand cranking till
new console arrives
▪ Re insert pump head
▪ Turn on pump to 1000 rpm & remove clamp
▪ Gradually increase rpm’s
 Pump head disengaged
▪ Clamp line & decrease pump speed
▪ Re-insert pump head
▪ Turn on pump to 1000rpm & remove clamp
▪ Gradually increase rpm’s
Note on HAND CRANKING the pump

 Clamp lines.
 Disconnect the pressure sensor and venous oximeter cables
 Open the safety bar
 Press on both locks on the joints of the safety bar and fold it upwards..
 Take the disposable PUMP out of the CARDIOHELP:
 Fix the disposable to the CARDIOHELP Emergency Drive hand crank
 Fit the disposable under the locating lug from below.
 Open the lower locking device. Swing the disposable right up to the pump drive and
release the lower locking device so that it fixes the disposable
 Unfold the hand crank handle.
 Open the clamp on the venous side and turn the hand crank clockwise
 When RPM is > 1500, unclamp lines and increase RPM
Hand crank
CARDIAC ARREST
 Cessation of native cardiac function
V-V V-A
 No patient circulation  Little hemodynamic effect if flow >

4l/min
 ECMO flow decreases
 Patient in cardiac arrest

with no output Mx
Mx  Establish adequate flow
 Call for help  Call for help
 CPR  Reversible causes
 Reversible causes  CPR may not be needed unless

pump compromised
DECANNULATION
 Accidental removal of access or return cannula
V-V V-A
 Hypoxaemia  Cardiac arrest
 Cardiac arrest depending on  Catastrophic if central

cardiac & respiratory reserve cannula torn off aorta
 Massive bleeding  Venous pulled out of atrium
 Peripheral blood loss from

site controllable
Prevention:
 Anchoring the cannulae to the patient
 Use of a spotter to ensure that lines remain free during patient manoeuvres
Management
 Call for help
 Clamp circuit
 Turn off pump
 CPR
 Establish ventilation & inotropic support
 Volume
 Peripheral: apply pressure
 Central: prepare chest opening
AIR EMBOLISM
 Introduction of air into circuit through connections or cannulation sites
 Massive embolus into the pump head will de-prime the pump with loss of ECMO support
Management
 Clamp arterial return line
 Stop pump
 Patient head down
 Increase ventilation & inotropes
 Volume
 If embolus entered patient arterial system (VA)
 hypothermia’
 Barbiturates, steroids, mannitol, lignocaine
 If embolus entered venous system (VV)
 Aspiration of right heart using existing lines
 Circuit Management
 Clamp circuit
 Turn off pump
 Ensure pump head outlet is at 12 o’clock position
 Examine site for air & seal if possible
 Further management requires perfusionist
CIRCUIT RUPTURE
 This is the disruption of any part of the circuit
 Massive blood loss
 Haemodynamic collapse and hypoxaemia of varying severity (depending on underlying
cardiac and respiratory reserve)
 Possible introduction of air into ECMO circuit
 Fracture and breakdown of polycarbonate components after being cleaned with alcohol
 Broken three way tap
 Accidental cutting or puncturing of circuit tubing
Prevention:
 Do not allow any part of the circuit to come into contact with alcohol or other organic
solvent such as volatile anaesthetic
 Allocated person to act as “spotter” to ensure that three way taps are not snagged on
anything during patient manoeuvres
 Care with needles and instruments near tubing
Management:
 Clamp the circuit on either side of the circuit disruption
 Call for help. Contact perfusion services and ICU consultant
 Assign roles for concurrent patient and circuit management
 Increase the ventilator settings and inotropes to compensate for loss of support.
 Give volume to replace blood loss
 If fractured three way tap: if possible place sterile gloved finger over leak
 Connection change
WEANING ECMO1,2,4,7
 Decision made by consultants & CT surgeons
V-V V-A
 Maintain ECMO  Heparin so ACT >400 to decrease risk clotting

flow rate
 Decrease pump flow 1litre while ventricular
 Re-establish pt function assess by TOE
full ventilation
 Period of low flow ECMO before decannulation
 Turn off 02 to
oxygenator  Respiratory function is a concern: turn off gas
flow (Only at circuit flows ≤1.5L/min) and assess
 6hr stability oxygenation achieved using the ventilator
then exclusively. Note: in this situation the circuit flow
decannulation acts as a right-to-left shunt. If adequate
oxygenation and CO2 removal can be
maintained in the presence of this shunt it is
likely that respiratory failure can be managed
without ECMO.
 If 02 good & C02 managed by ventilation
consider decannulation
Removal of cannulae:
 Removal of arterial ECMO cannulae should always be removed as an “open” surgical
procedure and be accompanied with the vessel wall repair.
 Venous cannula can be removed and pressure applied to the site for 20 minutes.
Post-decannulation Doppler:
 Lower limb venous Doppler studies should be performed following decannulation- as
prolonged femoral venous cannulation promotes distal DVT formation.
LEARNING ACTIVITIES
1. Define ECMO
2. Describe the two types of ECMO
3. What are the indications for ECMO?
4. What is the purpose of the oxygenator?
5. What is the function of the pump?
6. What is V-V ECMO more efficient at doing and how does it remove C02?
7. How much oxygen should be delivered to the oxygenator and what should it be set at
in relation to the ECMO flow rate for V-V ECMO?
8. What should the ECMO flow rate be set at for V-V ECMO?
9. Where are the access and return lines for CVVHDF connected on the ECMO circuit?
10. What are the safety checks that need to be performed for a patient on ECMO?
11. Why are the pre and post membrane pressures continuously monitored?
12. What is the management for “shaking” or “chattering” of the circuit?
13. Why are vascular observations important?
14. Why should oxygen saturation be measured on the patient’s right hand or forehead
for V- A ECMO?
15. What does the “SIG” alarm on the pump console signify and how do you rectify the
alarm?
16. What is the management for cardiac arrest for V-A and V-V ECMO?
17. Describe the process for weaning V-V and V-A ECMO.
REFERENCE LIST
1. Adult Extra Corporeal membrane Oxygenation (ECMO); Policy & Guideline. RPAH 2010
2. Extra Corporeal Membrane Oxygenation (ECMO) in the Intensive Care Unit. St Vincent’s Hospital
Sydney ICU 2010
3. European Heart Journal, Vol 26 issue 20. Favourable clinical outcome in patients with cardiogenic
shock due to fulminant myocarditis supported by percutaneous extracorporeal membrane
oxygenation
4. Gaffney, A.M., Wildhirt, S.M., Griffin, M.J., Annich, G.M. & Randomski, M.W. (2010).
Extracorporeal life support. BMJ, 341:982-986.
th
5. Guyton, AC & Hall, JE 2010, Textbook of Medical Physiology, 12 edition, W.B. Saunders
Company, Philadelphia
6. Luo, X., Wang, W., Hu, S., Sun, H., Gao, H., Long, C., Song, Y., & Xu, J. (2009). Extracorporeal
membrane oxygenation for treatment of cardiac failure in adult patients. Interactive CardioVascular
and Thoracic Surgery, 9: 296-300.
7. Marasco, S.F., Lukas, G., McDonald, M., McMillan, J., & Ihle, B. (2008). Review of ECMO (Extra
Corporeal Membrane Oxygenation) support in critically ill adult patients. Heart, Lung and
Circulation, 17S: S41-S47.
th
8. Tortora, G. & Grabowski, S.R., 2003, Principles of Anatomy and Physiology, 10 ed, John Wiley &
Sons, Inc, New York.

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2016

EXTRA CORPOREAL OXYGENATION (ECMO)

Paula Nekic, CNE Liverpool ICU SWSLHD

CVVHDF with ECMO 18

Weaning from ECMO 33

 Superior vena cava

 Inferior vena cava

 Carries deoxygenated blood from the lower body to right atrium

 Carries oxygenated blood from the Left ventricle to the organs

 Carries deoxygenated blood from the Right ventricle to the lungs

Principle veins and arteries

 Veins carry blood to heart

 Arteries carry blood away from heart to lungs to be oxygenated

EXTRA CORPOREAL MEMBRANE OXYGENATION (ECMO)

ECMO evolved from cardiopulmonary by-pass.

There are two types of ECMO, veno-venous and veno- arterial.

Figure 1: ECMO Circuit

Absolute Contraindications to Veno-Venous ECMO

Absolute Contraindications to Veno-Arterial ECMO

Relative Contraindication to Veno-Venous ECMO

Relative Contraindication to Veno-Arterial ECMO

ECMO Cannulae (stored in Theatre)

ECMO: initial set-up items:

Further items that should remain with the patient:

 Spare ECMO circuit

SWEEP GAS & OXYGENATOR CENTIFUGAL PUMP & SENSOR

Figure 2: ECMO Equipment

Figure 3: Centrifugal pump

Cream applied here

Figure 4: Rotaflow drive Rotaflow emergency hand crank

Rotaflow emergency hand crank

Blood flow rate: LPM

Pump speed: RPM

Dial for controlling pump speed

Figure 5: Pump console

Heater / Cooler Machine

Pre and post

Figure 7: Pressure Monitoring

The trans-membrane pressure gradient should be less than 50mmHg

A steadily increasing trans-membrane pressure without a concomitant increase in the circuit

Figure 8: Pressure monitoring points post oxygenator

Figure 9: ECMO Cannulae

Figure 10: The Avalon Elite Multi-Port Venous Femoral Catheter

Figure 11: ECMO Circuit

VENO VENOUS ECMO

Second access cannula :using SVC

Access cannula: using IVC

Figure 12: An example of Veno-venous ECMO

V-V ECMO and CO2:

V-V ECMO and O2:

Figure 13: An example of Veno – Arterial ECMO

V-A ECMO may be applied via central or peripheral cannulation

V-V AND V-A ECMO

 Provides respiratory support  Provides complete respiratory

 Increasing O2 sweep gas

CONNECTING CVVHDF TO ECMO

Figure 14: Access Line for CRRT connection to ECMO Circuit

Figure 15: Return Line for CRRT connection to ECMO Circuit

Securing Access and Return Lines

Figure 16: Securing ECMO Lines

 Ensure AC power alarm is turned on when using wall power

Their contact details should be left at the patient’s bedside.

Typical ventilatory goals would be:

TYPE:- ______ COMMENCED:- _ FILTER CHANGED:-______